Rankings in our society are ubiquitous. States are often ranked on
indicators such as education, income, taxes, health status,
eco-friendliness, and pollution. This study ranks states on how
hazardous they are to the health of the citizenry in terms of their
policies, expenditures, and regulations. States were ranked (1 for best
and 50 for worst) for each variable within each of four categories
(health promotion, health protection, the environment, and economic
well-being) as well as an overall ranking. Policy makers, state
legislators and civic and professional organizations, as well as
concerned individuals, may use these rankings to initiate or enhance
policies and regulations. Health administrators, public health and
health care professionals may use these rankings to determine methods
for improving and enhancing the health services, programs, and behaviors
in their communities. Overall the state rankings were varied. In
general, states that ranked high in the overall category scored
relatively high in all categories. However, exceptions were noted. An
association was found between how states voted in the 2008 Presidential
Election and how they ranked in terms of being hazardous to population
health.

Government Agency: United States. Centers for Disease Control and
Prevention

Accession Number:

308741527

Full Text:

INTRODUCTION

Rankings in our society are ubiquitous. These include rankings of
companies, cities, universities, and vacation resorts. States are often
ranked on indicators such as education, income, taxes, health status,
eco-friendliness and pollution. Rankings can be used for many purposes.
They may be used by politicians, policy makers, bureaucrats, businesses,
and interest groups, as well as individuals, to advocate for change or
maintenance of the status quo. Individuals may find rankings useful for
seeking employment, business opportunities, or a wide range of quality
of life issues such as where to live and work.

On March 23, 2009, USA Today published an article ("Study
measures states by personal, economic freedoms", page 4) by Julie
Carr Smyth of the Associated Press that summarized a study conducted by
William Ruger and Jason Soren for the Mercatus Center at George Mason
University (2009). It received media attention for their ranking of
states based on an index of "personal and economic freedom."
The study examined state and local interventions across a variety of
public policies, such as seat belt laws, tobacco taxes, drug policies,
minimum wage, and home school laws. These variables were then ranked by
each state according to how much "individual freedom" they
allowed. For example, stringent seat belt or motorcycle helmet laws were
considered infringing on personal freedoms, so states with the most
stringent laws were ranked low on the "freedom" scale.

On the opposite end of the spectrum, state policies and regulations
can promote the well-being and safety of individuals. The absence of
these regulations can be viewed as hazardous to your health. As Ruger
and Soren classified laws such as seat belt laws as infringing upon
personal freedoms, we view these laws as protecting the safety and
health of individuals (Ruger & Soren, 2009). State laws such as
speed limits ensure the safety of drivers by providing safe guideline
for speeds and without speed limits, roads and highways would become
extremely dangerous for individuals. Other laws such as smoking bans
help protect individuals' health and ensure them a safe, clean
environment in certain public places, free of harmful tobacco smoke. As
state laws and policies play such a vital role in the health and safety
of individuals, states lacking these policies can be considered
hazardous to your health.

PURPOSE OF THIS STUDY

According to the World Health Organization, health is a result of
genetic predisposition, environment and the community in which we live,
public and health policies and practices of our government, and medical
care (Evidence Base of Health Determinants, 2009). In contrast to the
Ruger and Jason Soren study, this study ranks states on how hazardous
they are to the health of the citizenry in terms of their policies,
expenditures and regulations. In order for greater specificity, we will
not only provide an overall ranking, but rankings for various
categories. These categories are comprised of health promotion, health
protection, the environment, and economic well-being.

SIGNIFICANCE OF THE STUDY

In our view, policies and regulations, which encourage and maintain
the health of residents are important. The lack of such policies and
regulations can be hazardous to one's health. This study may
provide useful information to a variety of stakeholders. Policy makers
and state legislators may use these rankings to develop and improve
policies and regulations. Similarly, health administrators, public
health professionals, and health care employees may use these rankings
to determine methods to improve and enhance the health services,
practices and health status in their communities. The media may use
these data to enhance the public's awareness of the policies,
programs, and regulations within their states that promote safety and
well-being as well as how well their state ranks in promoting these
aspects compared to other states. Individual citizens and organizations
may use the rankings to decide which state best fits the health and
safety needs for themselves and their family, and become involved in
health policies and regulations in their states and communities.

METHODS AND DATA COLLECTION PROCEDURES

For the purposes of this study we utilized a multistage process. To
begin, after explaining the purpose of our study, we asked experts in
the field of public health to suggest variables to use in the study. We
reviewed statistical information on different state rankings from
"Freedoms in the 50 States" (Ruger & Soren, 2009),
America's State Rankings (The United Health Foundation, 2008), and
Kaiser's Family State Health Facts (2008). After reviewing these
sources we returned to our group of experts to refine and categorize our
variables. We selected 25 variables in four categories. They include:

* Health Promotion: Any activity that promotes or supports the
initiation or maintenance of a behavior conducive to health.

* Health Protection: Any activity undertaken by a third party, such
as governmental institution or business, to enhance or maintain the
health of citizens.

* The Environment: Planned and structured interventions to the
physical or social environment to enhance or maintain the health of
citizens or to support change or maintenance of a behavior conducive to
health.

* Economic Well-being: Any activity or funding that promotes or
supports the economic wellbeing of citizens.

After identifying the 25 variables, we placed them into one of the
four categories and entered the data for analysis using SPSS Version 17.
The 25 variables and ranking systems include:

HEALTH PROMOTION (7 VARIABLES)

Tobacco Prevention--Tobacco has been associated with an increased
risk of throat cancer, heart attack, raised blood pressure, lung cancer,
respiratory disease, and other diseases. State spending on tobacco
prevention helps promote awareness of the effects of smoking. The
American Lung Association, in State of Tobacco Control 2008, provided
grades of A, B, C, D, or F to all states based on how much they spent on
tobacco prevention and control (2008). The grades were based on how
states established tobacco programs based on the Centers for Disease
Control and Prevention's (CDC) five components critical to a
tobacco control program. These components include state and community
interventions, health communication interventions, cessation
intervention, surveillance and evaluation, and administration and
management. The scores were also based on the CDC's recommendation
of overall level of funding for each state's tobacco control
program (2008). We converted their grades to numeric scores where A = 1,
B = 2, etc. States that had been given the same grade were considered
tied. Tied states were all given a mean ranking. For example, if 5
states were rated 1 (A), all were given a ranking of 3 on the scale of 1
to 50.

Beer Tax--Alcohol consumption increases the risk for cardiovascular
disease, stroke, depression, and other diseases. States with higher beer
taxes provide a negative incentive for residents to buy beer. Using data
from the Tax Foundation, we ranked the states from 1 to 50 based on beer
taxes per gallon, where the state with the highest beer tax was ranked 1
and the state with the lowest beer tax 50 (State Sales, Gasoline,
Cigarette, and Alcohol Tax Rates by State, 2009).

Immunization Coverage--Immunizations are important for preventing
the development and spread of disease. In their 2008 report,
America's Health Rankings, the United Health Foundation ranked
states by their immunization coverage of children ages 19 to 35 months.
The immunizations included in the study are the suggested early
childhood vaccinations including DTP, Poliovirus, MCV, HiB, and HepB.
Early childhood immunization is a safe and cost-effective method for
controlling diseases in a population (America's Health Rankings
2008: Immunization Coverage, 2008). The state with the highest
percentage of immunization coverage of children ages 19 to 35 months
received the highest score of 1.

Sexually Transmitted Disease (STD) Prevention Spending Per
Capita--Sexually transmitted diseases are an increasing problem in the
U.S. Through education and prevention programs, citizens can learn how
to prevent and protect themselves from STDs. Based on the Kaiser
Foundation's State Health Facts, we ranked states on how much they
spent on STD prevention (The Kaiser Foundation, 2007). We first took the
amount spent in each state in 2007 according to Kaiser and then divided
this number by the population in 2007 to obtain the amount spent per
capita. We then ranked each state based on how much they spent on STD
prevention per capita, where 1 was the highest amount per capita.

Required Physical Education--Obesity is linked with diseases such
as cardiovascular disease and diabetes. Lack of adequate exercise is
major risk factor for obesity. Physical education in schools is an
effective way to prevent childhood obesity and promote physical activity
among youth. Based on information provided by the National Conference of
State Legislatures, we rated states 1 to 6 based on their required
amount of physical education (Physical Education and Physical Activity
for Children, 2005). The highest score of 1 was given to states
requiring physical education K-12 with duration or frequency standards.
A score of 2 was given to states requiring physical education K-12 with
no duration or frequency standards. A score of 3 was given to states
requiring elementary and/or middle school physical education with
duration standards and some high school physical education requirements.
A score of 4 was given to states that had physical education required in
varying grade levels and no high school physical education requirements.
A score of 5 was given to states that required only some high school
physical education to graduate. The lowest score of 6 was given to
states that required no physical education at the state level.

Cigarette Tax--Cigarettes are associated with an increased risk of
diseases such as throat cancer, lung cancer, and respiratory disease.
Cigarette taxes add a negative incentive to smokers as well as those
considering smoking. Based on data provided by the Tax Foundation, we
ranked states on their cigarette tax per pack (State Sales, Gasoline,
Cigarette, and Alcohol Tax Rates by State, 2009). The higher the state
taxes on cigarettes, the higher the ranking the state received.

Child Care Regulation--Child care regulations insure the safety and
quality of care for children attending child care facilities. In the
National Association for Child Care Resources and Referral Agencies
report, We Can Do Better: NACCRRA's Ranking of State Child Care
Stands and Oversight, each state was scored out of 100 based on
regulations in child care facilities. Some of the regulations include:
staff to children ratios, background check requirements, health and
safety requirements, and education qualifications and annual training
requirements for teachers (2007). We used these scores to rank states
from 1 to 50; the state with the highest score from NACCRRA received a
score of 1.

HEALTH PROTECTION (8 VARIABLES)

Driver Safety--State driving laws are important for protecting the
safety of individuals on the roads. In the report, How State Laws
Measure Up, states were graded based on state laws promoting driver
safety. The states were ranked in six different categories including
DUI/DWI, young drivers licensing, safety belt use, child restraint use,
motorcycle helmet use, and red light cameras (Insurance Institute for
Highway Safety, 2009). Each state received a score of good, fair,
marginal, or poor for each of the six categories. After converting the
scores to a numeric scale of 1 to 4, we combined the scores from all six
categories and developed an average score for each state. Finally, we
ranked states 1-50 based on these averages.

Gun Control--Gun control laws are important for preventing
individuals from unsafe gun practices and promoting the importance of
gun safety. In 2008, the Brady Campaign, a national organization
dedicated to prevent gun violence, created a state scorecard ranking of
1 to 50 based on state gun laws (Brady Campaign State Scorecard
Rankings). The Scorecard is based on 100 points across five major
categories of laws: curbing firearm trafficking, strengthening Brady
background checks, child safety, banning military-style assault weapons,
and making it harder to carry guns in public places. The state with the
highest score received the rank of 1.

Emergency Preparedness--In emergency situations it is important for
a state to have a plan to distribute resources and protect citizens. In
2009, the Trust for America's Health created a report scoring each
state from 1 to 10 based on their total emergency preparedness,
including plans for distributing emergency vaccine and medical supplies,
and other plans needed for a public health or bioterrorism emergency
(Total Emergency Preparedness State Score). We then ranked each state 1
to 50 based on their scores.

Rural Speed Limits--Speed limits are necessary to ensure drivers
are maintaining safe driving practices. Using information provided by
Insurance Institute for Highway Safety, we ranked states by their
maximum rural speed limits (Maximum Posted Speed Limit, 2009). States
with lower speed limits received higher rankings than those that had
higher speed limits.

Urban Speed Limits--Similarly to rural speed limits, we ranked
maximum urban speed limits based on information provided by the
Insurance Institute for Highway Safety (Maximum Posted Speed Limit,
2009). States with lower speed limits received higher rankings than
those that had higher speed limits.

Fluoridation--Fluoridation of water helps prevent dental decay and
promote dental health. The National Institute of Dental and Craniofacial
Research ranked each state 1 to 50 based on the community water
fluoridation status of each state (Community Water Fluoridation Status
by State, 2009). States with the highest percentages of the population
receiving fluoridated water received the highest rankings.

Public Health Funding--Public health funding enables states to
develop programs and provide resources to promote the health of the
public. The United Health Foundation, in their report America's
Health Rankings 2008, developed state rankings measured by dollars per
person spent on public or population health received from the Centers
for Disease Control and Prevention (CDC), the Health Resources Services
Administration and the state (2008). States that spent more on public
health received higher rankings.

Mental Health Care Funding--Mental health care spending provides
resources for individuals with mental health needs. Based on information
provided in the Mental Health America's report, Ranking
America's Mental Health: An Analysis of Depression Across the
States, we ranked states 1 to 50 based on their per capita spending on
state mental health in 2007 (Mark, Shern, Bagalman, & Cao).

ENVIRONMENT (5 VARIABLES)

Parks and Recreation Funding--Parks and other recreational
resources can impact physical and mental health. Based on information
provided by the U.S. Census Bureau in 2000, states were ranked by their
expenditure per capita on parks and recreation (State and Local
Government Finances and Employment). Using the total money spent by each
state, we divided this number by the population in 2000 to find the per
capita spending. The more a state spent on parks and recreation, the
higher their rank.

Bike Friendliness--States that promote a safe environment for
bicycles provide more opportunities to be physically active. The League
of American Bicyclists ranked states 1 to 50 based on six key areas to
develop an overall score of bike friendlessness. The six areas were
legislation, policies and programs, infrastructure, education and
encouragement, evaluation and planning, and enforcement (2009 State
Rankings, 2009).

State Environmental Output--Environmental hazards can negatively
affect the health of individuals. In the study State Environmental
Outputs, states were ranked based on their environmental outputs. These
outputs were based on air, water, lakes, ozone, and river factors in
relation to state policies (List & McHone, 2000).

Environmental Protection Programs--Protecting the environment can
help prevent environmental hazards. Based on data provided by the
Environmental Council of the States, we ranked the states on their
environmental spending (State Environmental Budgets and Budget Plans, FY
20052008, 2008). Using the amount of funding spent on environmental
programs in 2006, we divided this amount by the population of each state
in 2006 to obtain the per capita spending. We then ranked the states 1
to 50 based on their per capita spending.

Highway Spending--In order to protect the safety of individuals on
the road, highways must be maintained. Based on information provided by
the U.S. Census Bureau in 2000, we obtained the amount of highway
spending in each state (State and Local Government Finances and
Employment). We then took this amount and divided it by the state's
2000 population to develop a per capita spending on highways. Each state
was ranked 1 to 50 based on their per capita spending on highway
spending.

ECONOMIC WELL-BEING (5 VARIABLES)

Education Spending--Education is associated with better economic
and health outcomes. In order to rank states based on their education
spending, the elementary and secondary educational spending in 2007,
provided by Kaiser State Health Facts, was divided by the 2007 state
population to obtain a per capita spending on education (Distribution of
State General Fund Expenditures (in millions), SFY2007). Each state was
than ranked 1 to 50 based on their per capita spending on elementary and
secondary education.

Special Education--Special education is important to provide
resources to advance the well-beings of individuals with special needs.
Based on data provided by the U.S. Census in 2000, state spending on
special education was obtained (State and Local Government Finances and
Employment). The total amount spent in each state was divided by the
2000 state population to find the per capita spending on special
education. States were then ranked 1 to 50.

Public Assistance--Public assistance helps provide resources to
individuals in need. Based on information provided by the Kaiser
Foundation, the public assistance spending in 2007 was divided by the
2007 state population to obtain each state's per capita spending on
public assistance (Distribution of State General Fund Expenditures (in
millions), SFY2007).

Minimum Wage--Many people live on minimum wage pay. High minimum
wages provide individuals with higher income to promote their overall
well-being. Based on data provided by the U.S. Department of Labor,
states were ranked 1 to 50 based on their minimum wage in 2009 (Wage and
Hour Division).

Sales Tax--Sales tax is a regressive tax, as it places a burden on
lower income individuals who have to pay a larger percentage of their
income. Based on data provided by the Tax Foundation, states were ranked
based on the amount of their sales tax (State Sales, Gasoline,
Cigarette, and Alcohol Tax Rates by State, 2009). States that had a
lower sales tax ranked better than states that had a high sales tax.

LIMITATIONS OF THE STUDY

The rankings in this study are based on 25 variables. Clearly there
are many others that could have been included. To address this concern
we selected variables identified by a pool of public health and health
education experts both in academe and in practice. Nor do we imply that
our list is a definitive ranking. Use of other variables would likely
result in somewhat different findings. However, correlation coefficients
among most variables indicate a positive correlation that would probably
occur with other similar variables. Ranking in this study should be
considered flexible in that they are subject to change on an ongoing
basis. For example, most states have increased tobacco taxes and smoke
free laws significantly over the past few years. Further changes are
likely to be enacted.

In addition, the data for all variables are not from the same year
due to data availability. However, data used to rank each individual
variable are from the same year and all variables are from data within a
relatively narrow time frame in an attempt to minimize significant
variations over time.

This study was limited to state policies and expenditures. A state
that received a low rank does not necessarily translate into poor
population health. Many towns and municipalities address some of the
variables found in this study. Unfortunately, the extent of their
efforts is unknown. However, our study does inform how states address
population health on a state level.

DATA ANAYLSIS

Prior to ranking we present the findings of the 25 variables in the
four categories in terms of the mean, median, and highest and lowest
ranking states.

Ranking by Category--States were ranked (1 for best and 50 for
worst) for each variable within each of the four categories. Rankings
for variables within each category were then averaged for each state.
Average scores were then ranked from 1 to 50 for each of the four
categories.

Overall Ranking--An overall ranking of states was calculated by
averaging the ranks for all 25 variables and then ranking the average
score for each state.

To assess associations between categories and overall ranking we
ran correlations using SPSS Version 17.

Finally, to augment tabular data we utilized ArcView, a Geographic
Information System (GIS) software product. Using ArcView, we created
layered maps which provided a pictorial and spatial presentation of the
ranking for each category and overall ranking.

RESULTS AND DISCUSSION

Results of the 25 variables in the four categories in terms of the
mean, median, best (lowest number) and worst (highest number) are
presented in Table

1.

HEALTH PROMOTION

Tobacco Prevention and Control--Tobacco prevention programs can
decrease the incidence of smoking particularly in youth through
education. Furthermore, they can provide support programs for current
smokers and increase the awareness of the negative consequences of
smoking. We converted their grades to numeric scores where A = 1, B = 2,
etc. obtained from The American Lung Association's report, State of
Tobacco Control 2008. The finding that only two states, Alaska and
Delaware received the highest score of 5 while 41 states received the
lowest ranking was discouraging. While it appears that some have
improved their score over the past several years, it is clear that there
is significant room for improvement.

Beer Tax per Gallon--Taxes on beer showed a wide variation with
Wyoming the lowest at $0.02 cents per gallon and Arkansas significantly
higher at $1.07. The median tax was $0.19 and the mean tax higher at
$0.28 due to several states with much higher taxes. Only a quarter of
the states have more than a $0.33 tax. Given the wide variation it would
seem that states with low taxes might consider increasing this tax.

Immunization Coverage--Rankings of immunization coverage were based
on America's Health Rankings, of the United Health Foundation
(America's Health Rankings 2008: Immunization Coverage, 2008). In
their 2008 report, immunization ranged from more than 90% in New
Hampshire and Maryland to less than 70% in Nevada, with 32 of the states
having 80% or less immunization coverage. While none of the states fall
under 66% of immunization coverage, many states are failing to cover 20%
of their populations, which could affect the control of diseases within
the states.

Sexually Transmitted Disease (STD) Prevention Spending Per
Capita--As with most variables a wide range was reported in STD
prevention spending per capita with Maryland ranking first and Virginia
last. Spending was also normally distributed as evidenced by similarity
of mean spending of $0.39 and median spending of $0.37. With the rising
rates of STDs in the youth of the U.S., states should consider better
funded prevention of these diseases.

Required Physical Education--Based on information provided by the
National Conference of State Legislatures, we ranked states 1 to 6 based
on their required education as previously described. Overall, states
scored in the middle with a score of 3; that is, requiring elementary
and/or middle school physical education with duration standards and some
high school physical education requirements. Only two states (Illinois
and New York) received the highest ranking while Colorado and South
Dakota received the lowest ranking, requiring no physical education
requirement at the state level. Room for significant improvement appears
to exist.

Cigarette Tax Per Pack--The association between better smoking and
lung cancer has been well publicized for many years, yet people continue
to smoke. One way to get people from participating in this unhealthy
behavior is to add a negative incentive such as cigarette tax. The price
elasticity of cigarettes has been well established, with higher costs
associated with reduced consumption. The state with the highest
cigarette tax of $3.46 was Rhode Island. On the other end, South
Carolina had the lowest cigarette tax of $0.07. From these two states it
is apparent there is a wide range of cigarette taxes. Most states had a
cigarette tax of less than $2.00, with only 10% of the states having a
cigarette tax higher than this amount. With cigarettes taxes so critical
to the incidence and prevalence of smokers, some states may want to
reconsider their low cigarette tax. The trend toward higher taxation by
many states is encouraging.

Child Care Regulation--For child care regulations, the average mean
score for the states was 55, which is almost half of the maximum score.
In fact, 90 percent of the states scored a 72 or below. Rhode Island
received the highest score of 85 while Idaho received the lowest score
of 13. Based on the relative low scores of most states, states have a
lot room for improvement in child care regulations.

HEALTH PROTECTION

Driver Safety--In the report, How State Laws Measure Up, states
were scored based on six different categories. Overall, most states
scored fair, with a mean score of 2. California received the best score
while Montana received the worst score. While no state was ranked at a 4
"poor", it is apparent there is room for improvement.

Gun Control--Based on the Brady Campaign's state scorecard of
100 points, we ranked states 1 to 50 (Brady Campaign State Scorecard
Rankings, 2008). California, with a score of 79, was ranked the best
state while Oklahoma, Kentucky, and Louisiana placed last with a score
of 2.

Emergency Preparedness--In terms of emergency preparedness, most
states did fairly well, with more than 70% of states receiving a score
of 7 or above on a scale of 1 to 10. Louisiana, New Hampshire, North
Carolina, Virginia, and Wisconsin all received a perfect score of 10,
while Arizona, Connecticut, Florida, Maryland, Montana, and Nebraska all
received the lowest score of 5. While there is still room for
improvement, it appears many states are well prepared for an emergency.

Rural Speed Limits--The mean for rural speed limits for all states
was 70 mph, which is high compared to the lowest speed limit of 60 mph.
A high percentage of states had high speed limits with 60% of states
having a rural speed limit 70 mph or above. The state with the lowest
rural speed limit of 60 mph was Hawaii, while there were several states
with the highest speed limit of 75 mph.

Urban Speed Limits--The urban speed limits were lower than rural
speed limits, with both the mean and median around 65 mph. In addition,
70% of the states had a speed limit of 65 mph or lower. Again, Hawaii
had the lowest urban speed limit of 50 mph, while Idaho, North Dakota,
and South Dakota, had the highest urban speed limit of 75 mph. While the
urban speed limits are generally lower than the rural speed limits,
there is still are large range among speed limits.

Fluoridation--States with the highest percentages of the population
received fluoridated water received the highest rankings. Only 21 states
are provided 80% or more of their populations with fluoridation. While
some states such as Kentucky and Illinois have 99% of their populations
received fluoridated water, states like Hawaii and Utah are provided
less than 10%. As fluoridation is a critical factor in dental decay,
many states should considered increasing fluoridation in their community
water.

Public Health Funding--Only 12 states pro vided more than $100 per
person for public health. Hawaii spent the most money, $198 per person,
while Indiana spent the least amount of $33 per person. Public health
funding is important to provide prevention and health promotion programs
to citizens, and states who wish to promote the health of their
population should be encouraged to provide sufficient funding to public
health to serve these needs.

Mental Health Care Funding--In terms of per capita state spending
on mental health in 2007, Alaska spent the most ($288 per capita),
however, 70% of states spent $100 or less per capita on mental health.
With the importance of mental health becoming more publicized, states
may begin to acknowledge the importance of mental health spending.

ENVIRONMENT

Parks and Recreation Funding--Using information provided by the
U.S. Census Bureau in 2000, states were ranked by their expenditure per
capita on parks and recreation (State and Local Government Finances and
Employment). About 75% of states spent $25 or less per capita. Kansas
spent the least amount of $2 per capita while New Jersey had the highest
per capita spending at $73. The wide range of per capita park and
recreation spending noted suggests that many states might consider
increased spending in this area.

Bike Friendliness--In terms of bike friendliness, Washington
received the best score of 1 while West Virginia was ranked lowest.

State Environmental Output--Colorado ranked first while Oklahoma
and Louisiana ranked last. To improve their score and the heath and
quality of living for their citizenry some states should consider
changing environmental policies.

Environmental Protection Programs--For environmental protection
program spending, a wide range of spending among the states was noted,
with 75% of states spending $50 or less per capita. Delaware spent the
most ($288 per capita) while Nebraska, at least at the state level,
spent $0 per capita on environmental protection programs.

Highway Spending--Overall, highway spending was fairly high with an
average $105 per capita. Some states spent significantly more such as
Minnesota ($250 per capita), while other states spent much less (West
Virginia, $22 per capita). It is realized that the significant
difference in range of per capita spending may be due to how states fund
and organize their spending in this area.

ECONOMIC WELL-BEING

Education Spending--As with many other variables in this study,
there was a large variability among education spending per capita among
the states. While the average per capita spending was at $734 per
capita, a quarter of the states spent less than $533 on a per capita
basis. By far, the state that spent the highest amount was Hawaii
($1588), while New Hampshire spent $0 per capita.

Special Education--Overall, special education received a small
amount of money from states with 80% of states spending less than $20
per capita. On average they spent $17 per capita. Some states such as
New Mexico spent much more ($47) which others such as Nevada spent much
less ($11).

Public Assistance--For public assistance, there was a wide
variability among states per capita spending with Massachusetts spending
highest at $200 and North Dakota lowest at $0 per capita. Spending was
positively skewed as evidenced by a median per capita spending of $13
and mean per capita spending of $28. A quarter of the states spent less
than $7 while only 10% of the states spent more than $60.

Minimum Wage--Only 10% of the states had a minimum wage of $8.00 or
above. Washington had the highest minimum wage of $8.55, while the
average minimum wage was $7.25. A minimum wage should not be confused
with a living wage. A living wage is considerably higher than a minimum
wage and is a term used to describe the minimum hourly wage necessary
for shelter (housing and incidentals such as clothing and other basic
needs) and nutrition for a person for an extended period of time. This
standard generally means that a person working forty hours a week, with
no additional income, should be able to afford a specified quality or
quantity of housing food, utilities, transport, health care, and
recreation food, utilities, transport, health care and recreation. In
the U.S., the state of Maryland and several municipalities and local
governments such as San Francisco, Santa Fe, Albuquerque and Washington,
D.C. have enacted ordinances which set a minimum wage higher than the
federal minimum for the purpose of requiring all jobs to meet the living
wage for that region. States should evaluate their minimum wage to see
if it can sufficiently provide living wage for residents.

Sales Tax--There was not a wide range of sales taxes and 70% of
states had a sales tax of 6% or less. California had the highest sales
tax (8%) while several states had the lowest (4%) such as Alabama,
Georgia, and Wyoming.

RANKING BY CATEGORIES AND OVERALL RANKING

We also looked at the consistency of ranks across categories. State
rankings by category and overall ranking are presented in Table 2.

A distinct variability among state rankings was noted. Among the
top 10 states, only Vermont ranked in the top 10 in every category. All
of the remaining top 10 states except Washington were among the top 10
in 3 categories. Of the bottom 10 ranked states, Nevada was the only
state to be ranked in the bottom 10 for 3 of the 4 categories.
Interestingly, Nevada ranked in the top 20 for the environmental
category. Arizona, Idaho, Mississippi, Oklahoma, and Texas ranked in the
bottom 10 for 2 categories.

When looking at the category rankings, no states except
Vermont's category ranks were all in the same quintile (1-10,
11-20, 21-30, 31-40, 41-50). The majority of states were ranked in 3 or
more quintiles, suggesting a wide variation in rankings among the
states.

Some states did fairly well in some categories but poorly in
another as well as vice versa. For example, Connecticut scored in the
top 12 in health promotion, health protection, and economic well-being,
but ranked 47th in environment. Wyoming scored in the bottom 10 for
health promotion and economic well-being and 36th in health protection,
but scored 2nd in environment. Some states had similar scores across
categories, such as New Jersey which ranked between 5th and 13th.

While some trends among most categories were noted, this was not
the case with environment. Several states such as Alabama, Wyoming, West
Virginia, South Dakota, and Idaho had environmental ranks that differed
significantly from their other rankings. For example, Idaho scored in
the bottom 15 for economic well-being, health protection, and health
promotion, but ranked in the top 20 for environment. On the other end,
Alabama ranked in the top 25 for economic well-being, health promotion,
and health protection, but ranked last in environment. This
dissimilarity in environmental ranks suggests that states view these
policies in different ways than other categories.

To obtain a different perspective of state ranking we utilized the
data from Table 2 and applied GIS's ArcView to map each of the
categories and overall ranking. Use of this software allows a visual and
spatial presentation of the ranking data. These GIS mapping results are
shown in Figures 1-5. Further reference to the GIS findings are
presented later in this study.

RELATIONSHIPS BETWEEN CATEGORIES

To assess possible associations between categories, correlations
were calculated based on the average score of each state in each
category. A positive relationship would indicate that better ranked
states (lower scores) on one category were also ranked better with lower
scores on another category. Results are shown in Table 3.

Results from Table 3 indicate that health promotion is
significantly correlated with health protection (p. Health protection is significantly correlated (p. There is no relationship between any of the categories and state
population. That is, the size of the population does not appear to
influence ranks in any categories. This is informative in that smaller
states do not appear to be handicapped in any way by their population
size.

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RESULTS BY POLITICAL PREFERENCE

Although not an intended purpose of this study, when looking over
the maps we noticed a possible apparent association between state ranks
and voting in the 2008 presidential election. To evaluate this, we
correlated for which presidential candidate each state voted and their
ranking in this study. Results appear to show that states that voted for
the Democratic candidate (blue) have lower (better) ranks than those
that voted for the Republican candidate (red). Furthermore, we performed
a t-test on the comparison of state rankings and how states voted in
that election. A significant difference (p. CONCLUSIONS

Policies and regulations that encourage and maintain the health of
residents are important. The lack of such policies and regulations can
be hazardous to one's health. Using twenty-five public health
population-based indicators, we ranked states in terms of how hazardous
they are to population health. We not only provide an overall ranking of
states but rankings for various categories including health promotion,
health protection, the environment, and economic well-being. Overall,
Delaware ranked best and Nevada worst. However, a wide variability of
findings was noted not only between states but also between categories
within states. Consistency in rankings between categories was elusive.
While rankings between categories such as health promotion and health
protection were noted, this was not the case for the categories of
economic well-being and the environment. It seems that not only do
states approach these categories differently but also differently within
the states. Our findings suggest that rankings between states do not
appear related to the size of state population. However, use of GIS
mapping and subsequent statistical analysis evidenced a strong
association between overall state rankings and voting results in the
2008 presidential election with Democratic voting states (blue) ranking
more favorably than Republican voting states (red), indicating political
orientation may be informative.

This study may provide useful information to a variety of
stakeholders including policy makers, legislators and health
professionals to develop and improve policies, regulations, health
services, practices and the health status in their communities. The
media may use these data to enhance the public's awareness of how
well their state ranks in promoting the health and reducing hazards in
their populations. Finally, individual citizens and organizations may
find the ranking informative in efforts to improve community health.

ACKNOWLEDGEMENTS

The authors would like to thank the following individuals who
composed the expert panel that provided suggestions and guidance for the
variables used in this study: Beth Chaney, PhD, University of Florida;
Lee Crandall, PhD, Clemson University; Gus Dalis, EdD, Los Angeles
County Office of Education; James Eddy, DEd, University of North
Carolina-Greensboro; David Macrina, PhD, University of Alabama at
Birmingham; Julie A. Pryde, MSW, LSW, Champaign-Urbana Public Health
Department, IL; David Remmert MPH, DeWitt-Piatt Bi-County Health
Department, IL.

REFERENCES

American Lung Association. (2008). State of Tobacco Control 2008.
Retrieved August 30, 2009 from http:// www.stateoftobaccocontrol.org/

The Environmental Council of the States. (2008). State
Environmental Budgets and Budget Plans, FY 2005-2008. Retrieved August
30, 2009 from http://www.ecos.org/files/3058_file_M arch_2008_ECOS_
Green_Report_Appendix.pdf

The Insurance Institute for Highway Safety. (2009, October) How
State Laws Measures Up. August 30, 2009 from
http://www.iihs.org/laws/measureup.aspx

The Kaiser Family Foundation. (2008). The Centers for Disease
Control and Prevention (CDC) STD Prevention Funding, FY2007. Retrieved
from August 30, 2009 from www.statehealthfacts.org. Data Source:
National Alliance of State and Territorial AIDS Directors (NASTAD) at
http://www.nastad.org, Special Data Request, 2008.

The Kaiser Family Foundation. (2008). Distribution of State General
Fund Expenditures (in millions), SFY2007. Retrieved from August 30, 2009
from www.statehealthfacts.org Data Source: National Association of State
Budget Officers. (2007). www.nasbo.org

League of American Bicyclists. (2009). 2009 State Rankings.
Retrieved August 30, 2009 from http://www.
bikeleague.org/programs/bicyclefriendlyamerica/bicyclefriendlystate/rankings.php

The National Association of Child Care Resource & Referral
Agencies. (2007). We Can Do Better: NACCRRAs Ranking of State Child Care
Stands and Oversight. Retrieved August 30, 2009 from http://www.naccrra.
org/publications/naccrra-publications/we-can-do-better

National Conference of State Legislatures. (2005) Physical
Education and Physical Activity for Children. Ncsl.org; Data Source:
National Association for Sports & Physical Education; National
Association of State Boards of Education; Trust for America's
Health; Center for the Study of Social Policy; NIHCM Foundation.

The National Institute of Dental and Craniofacial Research. (2009,
March) Community Water Fluoridation Status by State. Retrieved August
30, 2009 from www.nidcr.nih.gov/DataStatistics/FindDataByTopic/ Water
Fluoridation/Community WaterFluoridationState.html. Data Source: Centers
for Disease Control and Prevention 2002 Water Fluoridation Reporting
System (WFRS).

Julia Hemphill, BS

Thomas O'Rourke, PhD, MPH, CHES

Blake Zachary, MHS

Julia Hemphill, BS, is in the Department of Kinesiology and
Community Health at the University of Illinois. Thomas o'Rourke,
PhD, MPH, CHES, is Professor Emeritus of Community Health at the
University of Illinois. Blake Zachary, MHS. Please address all
correspondence to Thomas O'Rourke, PhD., MPH, CHES, 1206. S. Fourth
St., Rm. 129, University of Illinois, Champaign, IL 61820. Tel: (217)
840-7036. Fax: (217) 333-2766. E-mail: torourke@illinois.edu